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PatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.

Incest can be defined as sexual activity with a person from within the immediate family. However, the exact relationships which can be construed as incest will vary from culture to culture. Many countries have laws that forbid incest but there is considerable variation in the exact nature of these.

In England and Wales the Sexual Offences Act 2003 created an offence of familial sexual abuse (this is covered in Scotland in the 2009 Sexual Offences Act, and in Northern Ireland in the Sexual Offences Order 2008). The aim of this law was to protect children up to the age of 18 from any form of activity that a person would consider sexual or indecent. The offender may be an adult or another child. It recognises the modern family unit and it defines familial sexual abuse as being between a person and their parent (including adoptive or foster), grandparent, child, grandchild, sibling or half-sibling, uncle, aunt, nephew or niece.[1]

Epidemiology

Incidence

Sibling sexual abuse is usually recognised as being the most common form of sexual abuse within families. It has been documented as being five times more common than father/stepfather abuse.[2] Father-daughter incest was reported by 2.5% of female participants in an anonymous computer-assisted self interview.[3] One study from Scandinavia looked at all child sexual abuse in one area:[4]

Girls were victims in 85% of the cases, boys in 12% and boys as well as girls in 3%.

Sexual penetration had occurred in 53.7% of cases and there was genital or other physical manipulation in 29.6%.

In 16.7% cases there was no physical contact but there was some kind of non-contact molestation or exhibitionism.

Most perpetrators (72%) were well known to the child.

The most severe violations (regarded as the ones where there was sexual penetration) were significantly more often committed by biological relatives, household members, or family friends than by strangers.

Presenting features

The offender is reported as male in most cases but female involvement may be under-reported. Although sibling incest is thought to be the most frequently occurring form of incest, the abuse of daughters by fathers or stepfathers is more commonly reported.[5] Abuse by stepfathers is up to five times higher than that by biological fathers. Physical symptoms may include:

Vaginal pain

Rectal pain

Vaginal discharge

Bleeding

Chronic dysuria

Bedwetting

Constipation

Incest is usually repeated and will often continue for many years. As the daughter reaches an age when she is able to resist or flee, the activity may be repeated with a younger sister. Though the profiles of incestuous families may vary, the father-perpetrator is typically an immature individual with low self-esteem, while the wife-mother is depressed, helpless or otherwise emotionally absent.[6] The father often uses alcohol to allay his inhibitions before molesting his daughters. Theories have proposed that girls allow the sexual relationship to continue to prevent family disunity.[7]

Psychological symptoms include:

Deliberate self-harm.

Nightmares.

Sleep disorders.

Aggressive behaviour.

Withdrawal.

Post-traumatic stress disorder.

Poor concentration.

Poor performance at school.

Depression.

Phobias.

Eating disorders.

Precocious sexual behaviour with peers.

Associated factors

The increase in the divorce rates may have placed more children at risk than previously. When women begin new relationships, they may unwittingly be putting their children at greater risk for sexual abuse from the men they date. The study by Stroebel et al identified risk factors for father-daughter incest.[3] In the study, father figures were included within the definition of father-daughter. These risk factors included:

Parents where the relationship involved verbal or physical fighting increased the risk of father-daughter incest five-fold.

Families where father-daughter nudity was accepted increased the risk.

Homes with a single-parent mother or where divorce/death of the father resulted in another man living at home, tripled the risk.

Maternal affection was protective - but the likelihood of being a victim of father-daughter incest was highest if a girl's mother never kissed or hugged her.

According to another survey, if the mother remarries, "the stepdaughters are over eight times more at risk of sexual abuse by the stepfathers who reared them than are daughters reared by their biological fathers".[8]

Management

If it is an emergencyIf you think it is an emergency (the child is at immediate risk of serious harm) then refer the child immediately to the police and social services for immediate action. The police can enter premises and remove a child to a place of safety for 72 hours.

If only suspicious

If an alerting feature or considering child maltreatment prompts you to suspect child maltreatment then refer the child or young person to children's social care, following Local Safeguarding Children Board procedures.

Consult the at-risk register via social services.

Consult a health visitor and colleagues.

Record concerns in notes and follow-up.

In suspected sexual abuse

Do not perform a forensic intimate examination unless you have the specialised training and facilities to do so - a routine general examination to check general health or other injuries may be appropriate.

Forensic examination by a paediatrician experienced in the area of child abuse will be needed.

A forensic examination should preferably be done within 24 hours of the event; up to 72 hours is acceptable. Where suspected sexual abuse occurred >72 hours previously, an examination should be done within 7-10 days.

Russell DEH; The secret trauma. Incest in the lives of girls and women. Rev Ed, New York: Basic Books, 1999

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.

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